Predictors of poor response to voice therapy in adult vocal fold nodules: a retrospective cohort study

PURPOSE: To identify predictors of poor response to standardized voice therapy in adult vocal fold nodules and to evaluate recurrence risk across treatment pathways. METHODS: We retrospectively reviewed 107 adults with vocal fold nodules treated between 2020 and 2024. Patients were categorized as: (i) voice therapy alone, (ii) delayed surgery after failed therapy, or (iii) primary surgery. Demographics, stroboscopic findings, acoustic and aerodynamic parameters, patient-reported outcomes (Voice Handicap Index-10, Vocal Fatigue Index), and clinician-rated perceptual evaluation (GRBAS) were analyzed. Therapy failure and recurrence were defined according to prespecified clinical criteria. RESULTS: Voice therapy was effective in 41/48 patients (85.4%). Compared with Group A, patients proceeding to delayed surgery had longer symptom duration, more professional voice use, and higher baseline shimmer and perceptual strain; 23/25 (92.0%) improved after surgery. Primary surgery patients had worse baseline measures; 30/34 (88.2%) improved but recurrence was higher (26.5%) than in delayed surgery (8.0%) or therapy alone (4.2%). On multivariable analysis, shimmer and VFI independently predicted therapy failure, while shimmer and GRBAS strain independently predicted recurrence. CONCLUSION: Structured voice therapy remains first-line management. Elevated shimmer, perceptual strain, and high VFI identify patients at risk of failing conservative care and may justify earlier surgical consideration; professional voice use and longer symptom duration were associated on univariable analyses. Integrating objective acoustic and patient-reported measures can guide individualized decisions and clarify surgical indications.